UNIVERSITY OF JORDAN

DENTISTRY 2016

Date of Lecture: 00/ 00/ 2019

Done by:
Huthaifa Doctor:
Nedal
Ahmad
Corrected
hamdan
by:

CONTACT US: ASNAN LAJNEH

Why We should know about wound healing process ?

Different origins :

Periodontal apparatus, periodontal ligaments , periodontium and the oral cavity in

general is a very complex environment because of its composition , as its composed
of four different tissues each of them is of different origin .

There are cells of ectodermal origin and other cells of ectomesenchymal origin (
ectodermal cells that became mesynchymal cells ) and that’s why the healing of
periodontium is very challenging .

Complex development suggests complex regeneration :

The formation and development of periodontal ligaments and cementum

(periodontium in general )is very complex , this makes things more complex and
complicated when talking about the regeneration .

Continuous bacterial aggression :

in addition we have continuous bacterial aggression affecting the periodontium

every single moment , and as we all know oral cavity the dirtiest spot in the body ,

so after telling all these factors , lets talk about why its important to talk about
periodontal wound healing ?

our goal in periodontal therapy is to provide the patient with acceptable aesthetics
and function , reaching this goal we have to understand what really happens to the
tissues during healing ,this will help us to plan and manage any changes that can
happen , and it will allow us to correctly plan and execute our treatment plan
according to the time line of healing process , we have to understand the biological
nature and the development in order to regenerate these tissues , so lets just have a
look on the cells and events that are involved in both the development and the
regeneration process .

Development and Regeneration :

1-we have the same cellular events in both development and regeneration ( all cells
need to migrate to the site then having an attachment in order to adhere to a surface
to be able to proliferate and once they finish proliferation they start to differentiate
and produce the extracellular matrix , and in case of mineralized tissues they have
to mineralize this extracellular matrix , but lets have a look on the cells involved in
both two processes :

2-in development we have : follicular cells , hertwig epithelial root sheath ( not
involved in regeneration ), odontoblasts , neural crest cells, endothelial cells , stem
cells and osteoblasts .
 3-In regeneration we have some common cells like : endothelial cells , stem cells
,neural cells , fibroblasts ,osteoblast , epithelial cells , INFLAMMATORY CELLS
(they are the reason of differences between Regeneration and Development and
the reason why we have some certain degree of repair in our healing sites after
surgery or after trauma

below this red line all the processes
are the same .
The ectodermal neural cells will
condensate, reorganize themselves in
Common
the space and some of them will
in both
change into mesenchymal cells to be
called (ectomesynchymal cells )
Then under the ifluences of certain
adhesion , migration and proliferation
factors , these cells will give different
types of progenitor cells .
And after certain number of
differentiation factors along with
different conditions they will
differentiate into variable tissues
Above this line is the difference
between regeneration and
development and what makes
regeneration a very hard process ,
actually in regeneration the first
step is clot formation , and the
blood clot along with inflammatory
process is the period that dictates
what happens later on , so if we
managed this period in the best way
possible we can be able to predict a
better result of regeneration , that’s
why we need to pressure the site
and squeeze it to make the blood
clot small , and the patient should
be inflammation free so I can
predict regeneration .
Dentinocemental junction development :
1-The formation starts with disintegration of the hertwig epithelial root sheath , then
Precementoblast cells start to communicate with the none mineralized dentinal
matrix .

2-After that cementoblasts will produce cementoblast implant collAGEn fibers in pre-
dentine and this will form the dentino-cemental junction that still not mineralized
(cementoblasts produces collagen fibers that cannot be present without matrix so it
will also make the matrix) .

3-Later on complete mineralization of the junction occurs .

………………………..

*in wound healing we either have primary, secondary, or tertiary

intention, depending on the situation of the tissues

Phases of wound healing:

1-Inflammation : reaches its peak in the first day( 12-24 hours after the trauma) , and
lasts up to three days then its overlapped with granulation tissue with its peak in the
fourth or fifth day up to 10 days then it enters wound contraction and maturation
phase and this differs according to the type of traumatized tissue .
 Events that take place through wound healing:

Clot formation
Function: It protects the underlying tissues and allows the migration of epithelial cells
for healing, and acts as a reservoir , for cytokines and GFs .

Inflammation and granulation:

neutrophils are the predominant cells
in the first 3 days , then macrophages
start to predominate as they phage the
remnants clean the site and act as a
reservoir for chemicals and cytokines .

Granulation tissue rich in blood

vessels and granular cells this tissue is
important as it allows migration,
adhesion and proliferation of stem cells
that are needed to regenerate this site
.
Angiogenesis starts with the 3 or 4 days
after injury .

*The needed cells for the healing process

are :

So when we have a wound (or

while you are doing scaling &
root planning) a blood clot will be
formed in the sulcus after few
minutes.

You can notice the RBC’s how

they are attached directly to the
root surface.

*In 1hr neutrophils fill the blood clot

6 hours later: because plaque
accumulation starts to
happen by now, neutrophils
will line the root surface to
debride it (decontaminate the
wound.)

After 3 days : “late phase of

inflammation” there is an
a)increase in the influx of
macrophages (which will
debride and clean the wound)
and an b)increase of GF
release - to form the
granulation tissue to act as a
matrix for the recruitments of
stem cells.

7 days later:

Replacement of the
granulation tissue by the cell
rich newly formed tissue takes
place. Then we enter the
maturation phase where we
have remodeling of the newly
formed tissue to reach the
functional adaptation.

Maturation heads toward one

or combination of these
depending on variable changes
affect the maturation process
In order to get a complete healing :

Connective tissue reattachment: reattachment means to have perpendicular

penetration of collagen fibers into the cementam or the bone

Steps :

1- Giant cells adhere and start some superficial resorption on the root surface
presenting Howships lacunae

2- And this will expose and demineralize the dentinal tubules, creating a
biologically altered root surface and reattachment occurs as what has happened in
dentinocemento formation ))))))))

So Howship lacunae, exposure of dentinal tubules and denudation of dentinal matrix

which means the removal of minerals. this is all called- biological alteration-root
surface we will have collagen fibers attachment.

Cementoblasts will insert the fibers perpendicular to these dentinal tubules then

mineralization takes place.

Such a problem in periodontal tissue environment that makes tissues hard to heal is
that there are different cells influenced by the same molecules .

Bone healing
first we need attachment, then proliferation of preosteoblasts, and migration of the
pre- odontoblasts followed by differentiation and formation of bone matrix and the
remodeling.

In the first day blood clot is formed and after 3 days, inflammation occurs and after a
week we will have a soft callus\granulation tissue.

After 3-6 weeks woven bone will be formed.

“immature bone” ( nonfunctionally adapted ) forms and at 8 weeks bone remodeling

into functionally adapted mature lamellar bone .

Bone remodeling process :

Starts as osteoclasts resorb the bone , and at a certain time reversal phase (
reversal of resorbtion ) occurs by osteoblasts , then bone matrix will be reminerlized .
SO if we want to recap the whole process of periodontal wound healing, first is the
a)vascular phase: clot formation “few mins to few days -2-3 up to 5 days” , then

b) inflammatory and granulation phase “ migration of polymorph nuclear cells

and macrophages, connective tissue attachment, wound contraction” then

c) periodontal regeneration “Angiogenesis, synthesis of extracellular matrix,

epithelization,then bone mineralization, cemental deposition, periodontal ligament
fiber attachment and orientation” and finally the

d) maintenance and remodeling and stability phase since they are under
continuous stress.

primary intention which involves the primary edges brought together using sutures.

Secondary intention where we have suture but the wounds margins cannot be
adapted to each other, and always resulting in scar formation ( except for socket
healing ).
Tertiary intention: infected primary or secondary , Sometimes we leave the tissues
open for several days deliberately, until the potential complications are resolved ( the
inflammatory phase will take longer time than normally ) . After that we can
approximate the edges of the wound , it can be a little bit different from what we
have taken in surgery , but they are completing each other .

We have another type of healing which is for partial thickness wounds ,(ex: when I
take a graft from the palate and the connective tissue become exposed , or when we
are doing gingivectomy with external bevel incision and the gum get exposed ), in
these cases healing gets by epithelization.

Migration of epithelial cells to the margins occurs with no wound contraction because
there is no collagen formation.

this wound healing process is a complex process because of the events themselves
, The different factors that are involved and the different origins and numbers of
tissues that are involved in the process , this complex process is influenced by
different and important numbers of factors that will render the process much more
complex and complicated , and those factors are :
Factors affecting periodontal wound healing :

1-Bacterial contamination
The first factor is bacterial contamination :
is one of the factors that will mostly
influence wound healing process that’s why
we never take a patient with poor oral
hygiene or gingivitis to the surgery , highly
bacterial presence causes inflammation and
bad results of healing .

2-Innate wound-healing potential

it depends on the differences between us regarding our capacity of wound healing

for ex : immune competent people usually have good innate wound healing
potential , because they have mesenchymal cells that are undifferentiated cells with
high proliferation rate, and they can regenerate themselves by asymmetrical mitosis
: a process when the mother cell gives two cells only one of them is identical to
mother .

As you see in the picture one mesenchymal cell gives bone , cartilage , muscle and
ct ,,,,

And because we know we have different types of cells with different turnover rates (
the fastest is epithelium and the slowest is cementum) and as we know that PD
cells need time and enough space to be able to produce and regenerate lost tissues
they came up with the idea of putting a separator occlusive membrane (guided
tissue regeneration ) an avoid the invasion of epithelium and connective tissue on
this space so the cells can fill the space , so this is another example of regenerative
approach that was developed based on our understanding of what happens during
the healing and during development .
3-Local site characteristics
Another factor is local site characteristics ,
three walls defect , two walls defect and one
wall defect , they will influence degree of
regeneration and wound healing that will
happen after our procedures.

4-Surgical
procedure/technique
The surgical procedure will have an
influence as well and as the surgery
become more complex wound healing
become harder , and it depends also on
how many procedures we are doing at
the same time .

Because of our understanding of

Initial
surgical w
procedures on wound healing ,
we try to develop less traumatic , less
invasive and more tissue friendly
approaches .

Ex :

Both are root coverage procedures

*Tunnel tech

*Coronal advanced flap tech Less disruption of blood supply

More disruption of blood supply Better results

5-Initial wound stability

The patient shouldn’t leave the clinic with bleeding, Oozing of wounds is acceptable
only in cases of extraction or few hours after surgery .

Complications of periodontal wound healing

1-Microbiota

2-Multiple, specialized cell types

3-Multiple specialized junctional complexes

4-Avascular tooth surface

5-Stromal – cellular interactions

Required steps for ideal periodontal wound healing

1-Elimination of infected, degraded, & necrotic tissues.

2-Availability of populations of progenitor cells.

3-Proliferation & differentiation of progenitor cells in response to soluble & ECM

Factors.

4-Migration of progenitor & specialized cells to healing site.

5-Establishment of a reservoir of progenitor cells in the healing site.

6-Newly formed tissues & ECM must be stably integrated, & undergo remodelling.

7-Repopulating cells should be capable of synthesizing appropriate growth &

signaling

factors to restore dynamic tissue homeostasis.

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